Whats your preferred method of a pericardial window for trauma - how do u do it?

[europeman]

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I had a trauma the other day (stab wound to chest below nipple) that required laparotomy and diaphram repair. Anyway, the FAST was equivical for pericardial fluid, so he needed a window. After the laparotomy, I just did it through the stab wound incision in the chest (sorta like a chamberlin; i just put a rib spreader through the large stab wound and did my window no problem).

Had I not been able to do it that way though, I don't know how to do a window.

Do you guys do it through the laparotomy if you are already in the belly? Do you have to resect the xiphoid?

thanks!

 

[dpmd]

Where was your diaphragm repair? I have enlarged the diaphragm injury before to take a peek at the heart. In those cases it made the xiphoid a non issue. Otherwise, just excise the xiphoid, finger dissect up to the pericardium and get in (carefully). Haven't done it that way for trauma, but did it on CT surg for purulent pericarditis with tamponade. With the belly already open I imagine it would be even easier to see.

 

[idiot07]

Very easy to do it through the central tendon of the diaphragm if you're already in the belly. Much easier then through the chest wall or subxiphoid route. Place 2 0 or 2-0 stay sutures in the diaphragm, make an incision and the pericardium is right there in your face. You should close your diaphragmatic defect afterwards. If you're not in the belly, subxiphoid is the way to go assuming no prev hx of sternotomy.

 

[ESU_MD]

Probably doesnt matter how you do the window.. Its only diagnostic.

If its positive for blood, then its median sternotomy ( at least on the boards )

 

[Buzz Me]

I cut down on the xiphoid, excise it if it's in the way, grab the diaphragm and pericardium with some toothed forcep/clamp and then either aspirate with a large-gauge needle or do a true window by cutting out a piece of the pericardium and seeing what comes out. If positive --> median sternotomy.

 

[europeman]

Idiot 7.... Tks. I guess u have to take triangular ligament from liver to do that and give u space.

Seems easy enough.... I'd just like to see one first!

Tks!

 

[navymd]

So a few things as they pertain to diagnostic windows for trauma (not any other indication):
1. Easiest to do through the belly especially if you are already there
2. You do not have to close the small hole you make as long as it is central tendon and has the liver abutting it
3. It can be done and has been described for trauma as a laparoscopic approach through the diaphragm
4. The big down fall for subxyphoid windows (in trauma) is it is rarely ever completely bloodless and this can cause you to have to guess whether it was a small amount of blood in the pericardium or was it run down.
5. Be cautious with FAST the false negative rates reported in the literature range for 0% to as high as 20%. You need to know what your false negative rates (these can kill)

 

[DrDawg]

Agree with NavyMD

Would add that anytime you do a diagnostic/therapeutic procedure you do it completely. Exploring a cavity through a stab or other wound is general a bad idea unless:
1. Neck violation of the platysma; If violation do a formal neck exploration
2. Abdomen violation of the peritoneum; if violation do a laparotomy

ATLS has removed pericardiocentesis from it algorithm

Just my thoughts

 

[europeman]

DrDawg,

The big trauma centers are no longer doing mandatory exploration of the neck or the abdomen for platysma/peritoneal violation from stabs.

It's certainly fine to explore if you are a low volume trauma institution or in the middle of no where without access to imaging/monitoring capabilities.

But Zone 2 neck platysma violation in particular though is not being explored at high volume trauma centers where cta (and if needed) laryngoscopy and endoscopy (or swallow study) are available as long as the patient doesn't have so-called "hard signs" (expanding hematoma, bruit, pt unstable, etc)

See eaST guidelines

I agree with you pericardialcentesis has no role in trauma

 

[DrDawg]

DrDawg,

The big trauma centers are no longer doing mandatory exploration of the neck or the abdomen for platysma/peritoneal violation from stabs.

It's certainly fine to explore if you are a low volume trauma institution or in the middle of no where without access to imaging/monitoring capabilities.

But Zone 2 neck platysma violation in particular though is not being explored at high volume trauma centers where cta (and if needed) laryngoscopy and endoscopy (or swallow study) are available as long as the patient doesn't have so-called "hard signs" (expanding hematoma, bruit, pt unstable, etc)

See eaST guidelines

I agree with you pericardialcentesis has no role in trauma

Sorry, I can see how my post may have sounded like I was suggesting exploring all neck wounds. That is not the point I intended to make. Thank you for clarifing.